Resolution to Improve Step Therapy in Virginia (PDF)

Submitted by Richmond Academy of Medicine

WHEREAS, step therapy or “fail first” protocols are policies, practices and programs established by utilization review agents that establish a specific sequence of interventions for specified medical conditions for enrollees. These protocols appear to be economically based in that they require patients to use a lower cost drug or service before permitting use of more expensive drugs or services, and

WHEREAS, step therapy is an established benefit management tool used by commercial carriers, self-insured employers, Medicare Advantage/Part D programs, and Medicaid as well as other utilization review agents such as pharmacy, radiology and therapy benefit managers and specialty pharmacies, and

WHEREAS, an increasing number of insurers are utilizing step therapy or fail first policies that require patients to try and fail one or more formulary covered medications before providing coverage for the originally prescribed non-preferred or non-formulary medication, and

WHEREAS, the decision-making process and/or clinical evidence for the step therapy or fail first protocols and appeal/override decisions are frequently not revealed, and

WHEREAS, if a patient changes insurers, or if a drug they are currently taking, is moved to a nonpreferred or non-formulary status, patients may be put through the step therapy process again even if the patient is stable, potentially causing great harm to the patient, and

WHEREAS, inappropriately applied step therapy can negatively impact patient health due to the delay in receiving clinically prescribed appropriate care, and

WHEREAS, there is frequently no transparent, efficient or expedited step therapy or fail first protocol appeal process in exceptional clinical situations, and

WHEREAS, the act of appealing these protocols creates an undue burden on health care providers, their staff and patients, thereby wasting valuable health care resources and increasing costs; therefore be it

RESOLVED, that MSV work with stakeholders to reform step therapy in Virginia to require health plans to cite clinical review data as justification for denials, create a uniform and expedited appeals process, and establish a process for patients who transition from insurance plans.

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This is a daily problem for patients and physicians.

MSV needs to take a strong stand on this, on behalf of Virginia patients and physicians.  This should be a high tier item, not relegated to a lower priority.  This would enhance the lives of ALL patients and physicians, and would have little chance to divide the House of Medicine.

Mitchell B. Miller, MD